he refers. It is satisfying, at any rate, that the procedure is approved of.

In the majority of cases in which an extra-uterine pregnancy is suspected a laparotomy will be indicated. When there is doubt as to the correctness of the diagnosis of either intra- or extra-uterine pregnancy I think a curettement for the purpose of substantiating the diagnosis

cent. The dangers from the production of abortion in normal pregnancies, brought about in the effort to make a diagnosis of suspected extra-uterine pregnancy, are slight, and in any event should not weigh against the terrible liabilities that lie in the path of overlooked extrauterine gestations.

Curettement in cases of extra-uterine disease or preg

nancy is liable to precipitate accidents. The American Journal of Obstetrics for November, 1896, reports Hofmeier and Löhlein as having observed the formation of an hematocele following curettement, which in some cases proved fatal. Hammerschlag reports a case followed by abscess of the parametrium. In preparing for a curettement of this sort, therefore, we should likewise prepare for a laparotomy, which, as in my case, could be performed at the same sitting. In the majority of cases a microscopic examination of the endometrium will not be necessary to one who is familiar with the various appearances of the lining uterine membrane.

I had hoped when I began this report to be able to present the infant alive. It lived three weeks, and after improving in appearance, losing to some extent the wrinkled, little-old-woman skin, and gaining some few ounces in weight, began to lose its nursing ability, and died from inanition. At the time of its delivery it showed the effects of lying in a surrounding medium that, while soft, was not like the amniotic fluid of a normal pregnancy. From the appearance of the placenta the fetus must have been without an amniotic covering for many weeks, as the amnion was everted, turned down, and adherent to the uterus, intestines, and peritoneum, the fetus lying amongst the intestines along the right side of the abdomen. The left foot was bent inward, resembling a talipes varus. The head, which lay between the fundus uteri and the promontory of the sacrum, was pressed somewhat out of shape, so that the parietal bones were flattened. Both these abnormal outlines largely disappeared before the child died. Its weight at birth was three pounds, four ounces.

It is interesting to note the peculiar arrangement of the circulation in the placenta. While attached on its base to a considerable surface of peritoneum, it did not draw its vascular supply from this surface, but from several vessels of from one-sixteenth to one-eighth of an inch caliber, which came from the Fallopian tube, and from a thick band of adventitious tissue, the origin of which, I think, was also from the left tube. Instead, therefore, of the chorionic villi, which were destined to form placenta at the site of the serotina pressing down against the degenerating decidua, that they might spread out over a broad base, as in a normal intrauterine development, and from which they might gain an extensive maternal surface for contact with the maternal blood, they were fed in this case by the direct entrance of large vessels into their villous ramifications. I think it can be safely said that the placenta, aside from the vessels entering the chorion, was entirely fetal in structure, which is a condition not ordinarily occurring in even tubo-abdominal pregnancy. By reason of this fact, namely, that the vascular supply arose from a few vessels, instead of from a general vascularized surface, the ordinary grave difficulty in abdominal pregnancy of removing the placenta without dangerous hemorrhage did not prevail. Even the ordinary firmness of adhesion did not exist; the placenta was easily separated, with the exception of some strong bands of adventitious tissue, the peritoneum being left therefore in a favorable condition for recovery.

PHOTOGRAPH AND SKIAGRAPH OF A GOUTY

HAND.1

BY A. L. FISK, M.D.,

OF NEW YORK.

R. F., male, aged forty-six, was referred to my class in surgery from the medical class at the New York Hospital in December last, to obtain, if possible, some surgical relief. He is a natural born American, as were both his parents. For many years his father suffered exceedingly with rheumatism. The man's occupation, so long as it was possible for him to follow it, was that of peddling oil from a wagon throughout the rural districts. He has always been in the habit of drinking freely of the malt liquors, but never of spirits. His first attack of gout was during the winter of 1876-77, in the great toe of the left foot; later in the same season a second attack occurred in the great toe of the right foot. Three years afterward, in 1880, both knees were affected; and, in the autumn of 1882, both wrists and hands were the seat of the disease. This attack was so severe that he was confined to his bed for four months. The gouty deposits in the hands appeared first in the left, which now is completely crippled, the fingers being bound down in the palm. The photograph and skiagraph, which were taken early in February last, show the condition of the right hand. The skiagraph demonstrates the fact, most perfectly, that the deposit of salts has occurred entirely in the tissues surrounding the bones and the joints, and not in them. This furnishes a means of differential diagnosis between gout and arthritis deformans.

MEDICAL PROGRESS.

Trans

Operation in Lumbar Fractures.-ENDERLEN (Deut. Zeitschr. für Chir., Bd. xliii, p. 329) treated a case of fracture of the sixth dorsal and first lumbar vertebræ with anesthesia and paralysis of the sphincter. Six months after the accident the patient died of phthisis. verse sections of various parts of the column revealed slight damage to the fifth and sixth dorsal vertebræ, as well as a considerable fracture of the first lumbar vertebra, the body of which had penetrated the spinal cord to the depth of four millimeters. The microscopic examination of the cord in this situation revealed an almost complete transverse injury, and above this an ascending degeneration.

Making use of this case in connection with the many cases of fracture of the spinal column in the lumbar region, recorded in medical literature, the author does not favor operative interference unless there is present a comminuted fracture or complicated fracture of the arch of the vertebræ, or where there is evidence of the penetration of the bone-fragments. Where these complications are not present it is an extremely difficult matter to make a differential diagnosis between simple concussion and trauma. In both instances early operation is contraindicated. even for the evacuation of a blood clot exerting pressure on the cord is an operation advisable. Experience proves that even after the lapse of three months from the recep1 Read before the Harvard Med. Soc. of New York, March 27, 1897.

Not

tion of an injury an almost complete rehabilitation is by no means a rarity. In one case recovery has been established even after the considerable lapse of 21⁄2 years. In cases where operation has been followed by good results, it remains doubtful whether the merit is due to the operation or the vis medicatrix naturæ.

The cord can tolerate a certain degree of pressure, but there are also authentic cases in which, after removal of callus masses and fragments of bone, to the pressure of which the cord has been a long time subjected, recovery has resulted. Even in these latter cases early operative interference is not advisable and three weeks, at least, should be allowed to elapse before resorting to surgical measures. As regards the seat of fracture, numerous autopsies establish that the body of the vertebra is the seat of injury in ninety-five per cent. of the cases. Of the cases operated on, fractures of the arch have been found to exist almost as frequently as those of the body of the vertebra, from which the writer concludes that fractures of the body are always to be considered as of serious import, while fractures of the arch offer more tangible points of vantage to successful surgical manipulation.

The Cause of Death after Extensive Burns.-AJELLO and PARASCANDOLO (Gazz, degli ospedali e delle clin., 1896, No. 83) conclude after elaborate investigations that the cause of death after burns is a toxic ptomain, and is not due to the toxins which may be produced in the burn by bacteria, nor to anatomic changes which the blood-corpuscles or the organs of the burned area may have undergone. They found that if the same portions of the body be excised and then burned that the injections of the fluids derived from them killed healthy animals, with the same symptoms as were exhibited by animals dying from the effects of their own burns. If the burned portions of an animal were quickly removed it exhibited none of the specific symptoms of burning and death therefrom. These symptoms were also avoided by thorough blood-letting, followed by immediate transfusion of healthy blood or artificial serum.

The Fate of Epithelial Masses Experimentally Introduced into the Circulation.-During the Congress of Italian Surgeons held in Rome in October last, SGAMBATI (Centralbl. für Chirurgie, No. 51, 1896) read a paper on this subject. Proceeding on the supposition that metastases in carcinoma are developed from little masses of the tumor carried along in the blood or lymph circulation, he attempted to reproduce these symptoms artificially, in order to see whether normal epithelium would lodge and grow in the same way as the abnormal cancer cells. For this purpose he selected the submaxilary gland and the testicle of dogs, preserved the integrity of their epithelium in a warm normal salt solution, and introduced little masses of the tissue into the veins of dogs. After a certain time the dogs were killed and the hemorrhagic infarcts in their lungs were examined microscopically. In most cases the embolic tissues were found to be more or less degenerated. In a single case, in which the dog was killed on the fourteenth day, there was a multiplication of the testicular epithelium which formed the embolus, present

ing the appearance of a tubular adenoma. The thrombus in which it lay only partially obstructed the vessel lumen, and to this favorable situation the author was inclined to attribute the cell-growth. In the case of ordinary cancerous metastases, where only a few cells are swept away at a time, the nutritive conditions would be equally or even more favorable.

Limitation of Rotation after Fracture of the Forearm.From a study of eighty-two cases of fracture of the forearm MINTZ (Centralbl. für Chirurgie, No. 52, 1896) concludes that resulting limitation of rotation may be due to: 1. Changes in the soft parts (ligamentous or muscular). 2. Changes in the bone. The latter are of three kinds : (a) Hypertrophic callous. (1) Union between radius and ulna. (2) Pseudarthrosis. (3) Lateral splinters of bone or masses of callous. (b) Excessive callous with dislocation of fracture ends. (c) Dislocation of fracture ends. (1) Exogenous form of dislocation described by Volkmann, and consisting in the bending of the radius over the ulna. (2) Endogenous, a form of dislocation described by Schmidt, and consisting in the union of the lower radius fragment in the position of pronation or the opposite.

The author makes clear the fact that fractures of the forearm must be individually studied, and not all treated alike according to a preconceived idea.

The Cause of Warts.—SCHAAL (Arch. f. Dermatol. und Syph., xxv, p. 207) saw a wart develop on his own finger in eight days, at a point where a number of minute glass splinters had entered the skin, but without producing any apparent wound. The wart was treated with caustic alkali and removed entire, and the splinters of glass were found in its base. The author raises the question whether all warts do not have a similar etiology. They occur usually on exposed portions of the body and especially in children whose tender skin, and their disposition to play in the sand and dirt, give abundant opportunity for the local irritation of the papillæ by foreign bodies.

The Surgical Treatment of Perforating Typhoid Ulcer.FINNEY (Annals of Surgery, March, 1897), from a study of fifty-two cases of perforating typhoid ulcer treated by operation (six of these are now reported for the first time), finds that:

I. Of all the so-called diagnostic signs most reliance is to be placed upon the development of a severe attack of abdominal pain coupled with nausea and vomiting, and a marked increase in the number of white blood-corpuscles. 2. The surgical is the only rational treatment of perforating typhoid ulcer.

3. There is no contraindication to the operation, surgically speaking, save a moribund condition of the patient. In performing this operation three things are te be done : First, to find and close the perforation; second, to empty and cleanse the peritoneal cavity; third, to effect and maintain a thorough drainage. The most satisfactory operation is performed as follows: An oblique incision six inches long is made in the right iliac region. The cecum, which is always to be recognized by its longitudinal bands,

is the guide to the ileum. From it as the starting point the coils of ileum are systematically drawn out through the abdominal wound, while one assistant wipes the intestine as it is withdrawn with gauze wrung out of a hot salt solution, and another assistant keeps it warm by means of hot towels. All of the affected intestine, even to the duodenum if necessary, should be thus treated. The whole of the peritoneal cavity should then be wiped systematically with gauze wrung out of hot salt solution, attention being directed especially to the pelvic region. Usually irrigation is unnecessary, but the intestines before they are replaced should be thoroughly irrigated and wiped dry. The worst coils should be last replaced and the sutured portion left next to the abdominal wound. Bismuth gauze should be packed around this coil and introduced into the pelvis if necessary. By this means good drainage is insured and escape of feces is provided for in case of extravasation. The abdominal wound should be tightly closed except where the drains escape, and if distension follows operation the bowels should be moved early and thoroughly by calomel in broken doses, followed by salts, and, if necessary, a high turpentine and soap-suds enema. If stimulation is necessary, more reliance is to be placed on hypodermics of strychnin, enemata of several ounces of hot, black coffee, and the transfusion into the cellular tissues under the breast of a quart or more of the normal salt solution, than on any other remedies.

A Clinical Report of the Chemical Examination of Two Hundred Cases of Human Breast-Milk.--ADRIANCE reached the following conclusions (Archiv. of Pediatrics, February, 1897), by an interesting series of experiments: Excessive fats are due to an excess of albuminous food, which causes vomiting, diarrhea, and loss of weight, or failure to gain at the proper rate. It may be treated by limiting the amount of nitrogenous elements in the mother's diet. Excessive proteids are due to lack of exercise. This is especially liable to occur in nervous women. It is shown by vomiting, diarrhea, with yellow or green stools, containing curds, and loss in weight, or failure to gain. By regulating the exercise of the mother the elements of the milk can be brought to the normal proportions with a consequent disappearance of the gastro-intestinal symptoms.

During the colostrum period the proteids are very apt to be in excess. This, however, usually passes off in a few days, and seldom requires treatment. Should it per

sist, it is best to pump the milk, and dilute it with water; or, if this be impracticable, to have a wet-nurse for the child. The influence of prematuracy is well marked; the proteids are much exaggerated, and extend over a longer period than in ordinary colostrum milk. Deterioration of human milk is marked by a reduction in the proteids and total solids, or in the proteids alone. This takes place normally in the latter months of lactation. If it occurs earlier it may be the forerunner of the cessation of lactation, or it may be improved by well-directed treatment. Unless a proper addition is made to the infant's diet, the diminution of proteids will be accompanied by malnutrition and gastro-intestinal symptoms.

Serum Test for Diagnosis of Typhoid Fever.-In the March number of the Amer. Jour. of the Med. Sciences, BIGGS and PARK detail the results obtained in experimentation with Widal's serum test in typhoid fever as carried on in the laboratories of the New York Health Deparment. In 108 cases in which, after the completion of the illness, a definite diagnosis of typhoid fever was clinically made, a marked immediate reaction occurred in the first test in seventy per cent. Of the nineteen cases which were examined in the first week, the percentage was nearly as high-namely, sixty-three per cent. The majority of cases which gave no reaction by the fourteenth day failed to give at any time a definite reaction. But in two instances reaction at first appeared at the middle of the fourth week, when the temperature had become nearly normal.

One case was of great interest, as proving that the blood of the typhoid patient may never throughout the whole illness have sufficient agglutinating properties to give a definite reaction in the usual dilution. This case presented the usual symptoms and course of typhoid fever, and by puncture of the spleen typhoid bacilli were obtained.

It was demonstrated that in a certain proportion of cases other than typhoid, there occurs a delayed moderate reaction in a one-to-ten dilution of serum to blood, but very rarely under such circumstances does this reaction occur within fifteen minutes.

It seems probable that a positive diagnosis may be reached in fifty per cent. of cases of typhoid fever and a probable diagnosis in half the remaining cases. While the absence of the reaction for several examinations does not exactly exclude typhoid fever, yet in doubtful epidemics where several cases can be examined the absence of reaction in all of them would clearly indicate that the epidemic was not one of typhoid. For further details the reader is referred to the original article.

THERAPEUTIC NOTE.

Causes and Treatment of Disagreeable Gustatory Sensations.-HERZFELD (Therapeut. Monatshefte, Jan., 1897) disputes the commonly accepted opinion that abnormal gustatory sensations are due to digestive disturbances. Aside from those cases due to affections of the teeth, pharanyx, and tonsils, he holds that the crypts in the tonsils often contain masses having a fetid odor. A simple inspection may not suffice to reveal these masses, as they may be situated behind the anterior pillar. With an instrument similar to a crochet hook their presence is easily demonstrated, and the crypts may be slit up in order to prevent a recurrence of the trouble. In other cases the source of the bad taste lies in the posterior nasal cavity, where sometimes a pouch (bursa pharyngea) secretes a mucopurulent liquid. In such cases a slight operation will cure the bad taste. Nasal affections, affec

tions of the antrum of Highmore, etc., are further responsible for some of these cases. The author warns against a too hasty conclusion that because of disturbed gustatory sensations the stomach is necessarily at fault.

AN

LEA BROTHERS & CO.,

No. 111 FIFTH AVENUE (corner of 18th St.), NEW YORK, AND NOS. 706, 708 & 710 SANSOM ST., PHILADELPHIA.

SATURDAY, APRIL 17, 1897.

EPOCH IN MEDICAL EDUCATION IN
NEW YORK.

THE announcement was recently made to the medical world that the University Medical School had legally become the Medical Department of the New York University, and had passed over all its goods and chattels and their unrestricted control to the safekeeping of the authorities of the University. Following closely upon the heels of this intelligence comes the statement that Bellevue Hospital Medical College, in response to an invitation from the University, has done the same thing. Hereafter these two friendly rivals will nestle in the bosom of a common alma mater, will be consolidated into one institution, and be known as the New York University Bellevue Hospital Medical College.

The students and alumni of the former institutions, which now pass out of existence, are expected to embrace each other as brothers, accept their foster mother, and be enrolled and known as alumni of the New York University. During the present year the combined enrollment of the two schools has numbered 1057 students, while the combined alumni number 11,434. There are 116 members of the two In the new arrangement they place them

faculties.

selves entirely under the direction of the University Council, and rely upon that body for their future selection and compensation. It is rumored that they will all place their resignations in the hands of the Council, leaving that body untrammeled in its selection of a faculty.

In this consolidation the University acquires ownership of all the property, rights, leases, and privileges of both institutions, and assumes all their obligations. The terms of the transfer are absolutely without condition.

It is impossible to estimate the importance of this action, or to conceive of the boundless possibilities it has in store for the advancement of medical education in New York City. By this arrangement there will be secured a faculty composed of two bodies of professional men, each one of which has been amply sufficient for the teaching requirements of a successful and prosperous school.

The financing of a medical school is a source of anxiety, or, at least, of constant care. The professors will now be relieved of this responsibility, and their only concern will be to see that they are provided with proper teaching facilities. This will add vastly to the esprit de corps, and the large number of teachers will permit of more individual, personal work. An opportunity is now afforded to banish forever the old system of didactic lectures, and introduce methods of instruction along more modern and improved lines. The duty of a college professor is no longer considered fulfilled when he has monotonously and automatically gone over a subject in the presence of three or four hundred drowsy, listless, inattentive students. The successful teacher is the one who throws such a charm about a subject as to arouse the interest and ambition of the student to pursue investigations on his own account, and then places within his hands instruments of precision, and provides methods of investigation which shall enable him to work out for himself the ultimate finalities of the subject. To educate is to draw out latent powers, not to fill up empty reservoirs.